Implant Esthetics:Form Meeting Function

bination of bovine bone mineral and the collagen membrane seemed to yield greaterimprovements in clinical parameters showing 0.9 +/- 0.2mm more in PD reductionand 1.0 +/- 0.3 more clinical attachment gain (32).

In this review several modalities have been evaluated as for treatment for peri-implan-titis. To date, none of the techniques have been shown to be predictable (Table 1.). Atbest, a 5-year follow-up study showed a 58% success rate. Moreover, no histologicalstudy has reported has reported significant re-osseointegration of a peri-implantitisaffected surface. Wetzel 1999 (39).

The ideal management of peri-implant infections should focus both on infectioncontrol of the lesion, detoxification of the implant surface, and regeneration oflost support. Treatment options can be surgical or non-surgical. In this review

was concluded that non-surgical treatment of peri-implantitis was unpredictable, while

the use of chemical agents such as chlorhexidine had only limited effects on clinicaland microbiological parameters. Adjunctive local or systemic antibiotics were shownto reduce bleeding on probing and probing depths in combination with mechanicaldebridement. Beneficial effects of laser therapy on peri-implantitis have been shown,but this approach needs to be further evaluated. Implant surface bacterial decontam-ination is the essential in treating peri-implantitis infections. In the studies described,establishing an adequate healthy tissue environment proved to be difficult sinceinflammation was still present in a significant number of patients. New treatmentmodalities need to be evaluated using long term randomized-controlled studies toidentify predictable and successful treatment of peri-implantitis.

bleeding on probing was statistically significantly greater and an improvement in meanperi-implant PD (from 3.9mm to 3.6 mm) was seen. These results suggest that the top-ical application of chlorhexidine provides limited or no adjunctive clinical improve-ment when treating shallow peri-implant lesions as compared with using mechanicaldebridement alone. (33)

Karring et al. (2005) studied the efficacy of sub-mucosal debridement without antibi-otics for the therapy of peri-implantitis utilizing an ultrasonic device or carbon fibercurettes. Karring concluded that there was no statistically significant difference report-ed for the implants treated either by the ultrasonic device or manually scalers frombaseline, three, and six months regarding reduction in bleeding on probing and radi-ographical bone loss. (34)

Schwarz et al. (2005, 2006a) compared the efficacy of the Er:YAG laser with that ofthe combination of mechanical debridement (using plastic curettes) and antiseptic(0.2% chlorhexidine digluconate) administration for the treatment of peri-implantitis.In both studies the results obtained at 6 months after therapy suggested that the treat-ment modalities were equally efficacious in significantly improving peri-implant prob-ing pocket depth (PPD) and clinical attachment level (CAL). However, at 12 months,

the mean values for both groups of peri-implant PPD and CAL were not statisticallysignificantly different from the corresponding values at baseline. Therefore the resultsof the Er:YAG laser seems to be limited to a 6-month period, particularly for advancedperi-implantitis lesions. (30)

Leonhardt et al. (2003) evaluated the 5-year outcome of a combined surgical (openflap) and antimicrobial treatment of peri-implantitis in humans. Leonhardt studied theeffect of systemic antimicrobial therapy (amoxicillin and metronidazole) together withan open flap procedure and in conjunction with mechanical debridement of theimplant surface for decontamination. The treatment was successful in 58% of theimplants treated during follow-up for 5 years (26). Smoking was found to be a nega-tive risk factor for treatment success.

Schwarz et al. (2006b) evaluated and compared the efficacy of two bone regenerativeprocedures for the treatment of moderate intra-bony peri-implantitis lesions thatincluded at a greater than 6mm probing depth and an intrabony component of 3mmas detected on radiographs. The defects were randomly treated either with a surgicaldebridement and filled with nanocrystalline hydroxyapatite, or surgical debridementand filled with bovine-derived xenograft (Bio-Osss, Geistlich, Wolhusen, Switzerland)combined with a bioresorbable porcine-derived collagen membrane (Bio-Gides,Geistlich, Wolhusen, Switzerland) (31). After two years the study showed that the com-

Moreover, only one study showed 5-year post treatment results with a 58 percent suc-cess rate.

Pontoriero (21) demonstrated the importance of bacterial plaque accumulation in thedevelopment of inflammation around implants (peri-implantitis) and Mombelli (15)showed that, if this condition is left untreated and the surface is not decontaminated,it will lead to peri- implant pocketing, alveolar bone loss, and eventually to implantloss. Because there are biologic differences between teeth and implants, the progres-sion of infection around implants is also different than natural teeth. The inflammato-ry cell infiltrate around implants was reported to be larger and extend more apicalwhen compared to a corresponding lesion in the gingival tissue around natural teeth(29). In addition, the tissues around implants are more susceptible to plaque associat-ed infections which spread into the alveolar bone (29).

Implant surface bacterial decontamination is essential in treating peri-implantitis infec-tions. Systemic administration of antibiotics has been used in the treatment of peri-implantitis resulting in a reduction of inflammation. However, in a systematic reviewof treatment Lindhe et al. questioned the use of antibiotics as a sole therapy for treat-ment (29). Moreover,in one study a 3-month recurrence of peri-implantitis was

observed after completion of antibiotic therapy due to bacterial recolonization of theimplant surface (14).

Because non-surgical treatment approaches failed to promote the re-osseointegrationof the exposed implant sites (37), additional surgical interventions have been used inorder to minimize the risk for a re-infection of the peri-implant pocket. Some of thetreatment modalities suggested for peri-implantitis are: 1) Sub-mucosal mechanicaldebridement and antimicrobial minocycline spheres (Arestin), 2) Mechanical ultra-sound debridement without antibiotics, 3) Er:YAG laser with mechanical debride-ment, chlorohexidine, with and without open flap surgery, 4) Antimicrobial therapywith open flap debridement, 5) Access flap surgery and nanocrystaline hydroxyap-atite.

Renvert et al. (2006) compared the combination of oral hygiene instructions, mechan-ical debridement and topical application of minocycline microspheres (Arestin) in peri-implant lesions (with bone loss corresponding to no more than three implant threads)to the combination of oral hygiene instructions, mechanical debridement and 1%chlorhexidine gel application. The results obtained after a follow-up period of 12months showed that with the Chlorohexidine group, only a limited reduction in bleed-ing on probing was achieved and the mean peri-implant probing depth (PD) remainedunchanged (3.9mm). On the other hand, in the minocycline group, the reduction of

Clinical data in this study was obtained from the Implant Database (ID). This datawas extracted as de-identified information from the routine treatment ofpatients at the Ashman Department of Periodontology and Implant Dentistry at

the New York University College of Dentistry (NYUCD) Kriser Dental Center. The IDwas certified by the Office of Quality Assurance at NYUCD. This study is in compli-ance with the Health Insurance Portability and Accountability Act (HIPAA) require-ments and approved by the University Committee on Activities involving HumanSubjects. This literature review includes a total of 358 articles referring to “peri-implantitis”,”Peri-implant diseases” (311 articles), ” treatment of peri-implantitis” (250articles), “surgical treatment of peri-implantitis” (218 articles), “re-osseointegration ofimplants” (188 articles), “microbiology in peri-implantitis” (94 articles), “laser treat-ment of peri-implantitis” (32 articles), “implant surfaces and peri-implantitis” (50 arti-cles), “peri-implantitis infection” (67 articles).The inclusion criteria for article consider-ation included:1. Treatment of peri-implantitis in human clinical studies.2. Treatment of peri-implantitis in animal clinical studies3. Re osseointegration of implants4. Peri-implant diseases5. Laser treatment of peri-implantitis

Based on this literature review, 39 of the 358 articles were included in this evaluation.

The results of the literature review revealed that although there are a number ofstudies using different modalities to treat peri-implantitis most of the studies onlyto have 6 to 12 month follow-up, with one study showing a 24-month follow up.

TTreatment of Preatment of Peri-implantitis – A Literature Reri-implantitis – A Literature RevieweviewVavalekas, Michail; Hanawa, Yasufumi; Dunca, Flaviu; Tetri, Baruch; Froum, Scott; Bral Michael, Cho, Sang-choon; Froum, Stuart; Elian, Nicolas; Tarnow, Dennis. Dennis. Ashman Department of Periodontology and Implant Dentistry, New York University

MATERIALS AND METHODS

RESULTS AND DISCUSSION

CONCLUSIONS

REFERENCES

INTRODUCTION

New York University

Author Procedures Patients and implants Follow-up Survival rate

Leonhardt, A etal. (2003)

Open flap debridement,Antibiotic: Systemic administra-

tion of Amoxicillin and metronida-zole

9 patients, 26 implants 6 months, 1 and5 years 58%

Karring et al.(2005)

Ultrasound debridement, NoAntibiotic used 11 patients, 22 implants 6 months 100%

Schwartz et al.(2005) (2006a)

No flap, Er:YAG laser, mechani-cal debridement, chlorohexidine

20 patients, 32 implants(2005), 20 patients, 40

implants (2006a)

6 months(2005), 12

months(2006a)100%

Schwartz et al.(2006b) (2008)

Open flap, nanocrystalinehydroxyapatite, or bovine bonecombined with a collagen mem-

brane

22 patients, 22 implants6 months(2006b), 2

years (2008)100%, 100%

Renvert et al.(2006)

Sub-mucosal mechanicaldebridement, Topical minocycline

microspheres or 1% chlorhexi-dine gel application

30 patients, 87 implants 12 months 100%

Fig 3a. Peri-implantitis around on external hex Fig 3b. Removed implants showing extend bone loss

Fig 4a. Peri-implantitis around on press-fit im Table 1. Comparison of different treatment modalities

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Peri-implantitis is an inflammatory process affecting the soft and hard tissues sur-rounding an implant. This disease is associated with loss of supporting bonebleeding on probing and occasionally suppuration. The etiopathogenesis of

peri-implantitis is complex and related to a variety of factors that affect the peri-implantenvironment. Peri-implantitis can influenced by:(1) Patient related factors includingsystemic diseases (e.g diabetes, osteoporosis) and prior dental history (periodontitis),2) social factors such as (inadequate oral hygiene, smoking, drug abuse) and 3) para-functional habits (bruxism & malocclusion). In addition to the above, iatrogenic fac-tors such as faulty restorations, cement left following restoration delivery and loosecomponents can also play a significant role in the development of peri-implantitis.

Although restorations of endosseous implants have demonstrated a very high survivalrate(1), one study suggested that over a 5 year period, 0 to 14.4% of dental implantsdemonstrated peri-implant inflammatory reactions associated with crestal bone loss(2).

Implant failure has been attributed to a variety of causes including: 1) bacterial infec-tion 2) poor surgical technique 3) premature fixture overload (7), 4) faulty or incorrectprosthetic design and/or 5) improper surgical placement (17). In cases where is evi-dence of progressive infection caused by bacterial plaque and resulting in progressivebone loss of bone around the implant, the etiology is considered to be peri-implanti-tis.

Many methods of treating peri-implantitis treatment have been documented in the lit-erature. This paper will focus on treatments that address bacterial contamination as theetiologic agent. Therefore methods of implant surface decontamination will bedescribed along with procedures designed to treat the bone loss caused by peri-implantitis (6, 10). These treatments include 1) administration of systemic antibioticsalone, 2) Mechanical debridement with or without systemic antibiotic treatment (38),3) Mechanical debridement with or without chlorhexidine oral rinses (38), 4)Mechanical debridement combined with LASER decontamination (30,38), 5) SurgicalDebridement (32) and more recently, 6) Surgical debridement with guided boneregeneration (GBR) for reparation of bony and soft tissue defects (6, 7, 8). To date,GBR using a bone graft and membrane has had the best success as in demonstratingbone fill of the defects associated with peri-implantitis as described in the literature (6,9).

The purpose of this literature review was to discuss different treatment modalities forperi-implantitis and the compare of the treatment outcomes.

Fig 1a. Peri-implantitis around on internal hex implant Fig 1b. Implant removal site

“…implant surface bacterial deconta-mination is the essential in treating

peri-implantitis infections. In the stud-ies described, establishing an ade-quate healthy tissue environment

proved to be difficult since inflamma-tion was still present in a significant

number of patients…”

Fig 1c. Implant removal with torque wrench Fig 1d. Healed after implant removal

Fig 2a. Peri-implantitis around a RTs implant Fig 2b. Peri-implantitis lesions surrounding implants

Fig 2c. Removed implants showing extend of infection Fig 2d. Site of implant failure due to peri-implantitis

This Presentation was Sponsored by New York University Department of Implant Dentistry

Alumni Association (NYUDIDAA) and the Office for International Program